“It was clear from the evidence that confusion arose over what advice had been given by…”
Dated 27 Apr 2016, from the coroner for Surrey. Sent to 5 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 22 Jun 2016. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated27 Apr 2016
- Deadline22 Jun 2016
- Published on judiciary.uk27 Apr 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Epsom and St Helier University Hospitals NHS Trust | Response publishedPublished on judiciary.uk in April 2016. |
| British Medical Association | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Surrey Downs Clinical Commissioning Group | Response publishedPublished on judiciary.uk in April 2016. |
| Care UK | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Linden House Surgery | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
– (1) It was clear from the evidence that confusion arose over what advice had been given by the GP on the 15th January 2015. No record was made in the multidisciplinary notes by the GP of her attendance at Milner House. Care UK the parent company of Milner House offered to liaise with their local surgeries to ensure the records were made by visiting GPs. However it appears that the BMA advice to GPs “Quality First Managing Workload To Deliver Safer Patient Care” advises against GPs filling in multi-disciplinary notes. There was no clarity about whose responsibility it was to fill in the notes. (2) Advice given by the GP over the telephone to make Mr Higgs “nil by mouth” was not recorded and no confirmation of that advice in writing was sent by email. There did not appear to be a safe system in place to ensure telephone advice was accurately sent and received. (3) There was conflicting evidence from Care UK and Epsom hospital about OOH provision at the hospital pathology laboratory for community care providers resulting in a significant delay to a diagnostic blood test being undertaken.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2016-0181
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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